CASE SERIES

Middle Fossa Approach for Resection of Vestibular

Schwannomas: A Decade of Experience

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Jennifer A. Kosty, MD∗
Shawn M. Stevens, MD‡
Yair M. Gozal, MD, PhD∗
Vincent A. DiNapoli, MD, PhD∗
Smruti K. Patel, MD∗
Justin S. Golub, MD§
Norberto O. Andaluz, MD∗
Myles Pensak, MD‡
Mario Zuccarello, MD∗ ‡
Ravi N. Samy, MD∗ ‡
∗
Department of Neurosurgery, University
of Cincinnati Medical Center, Cincinnati,
Ohio; ‡ Department of Otolaryngology
Head and Neck Surgery, University of
Cincinnati Medical Center, Cincinnati,
Ohio; § Department of Otolaryngology—
Head and Neck Surgery, Columbia
University Irving Medical Center, New
York, New York
This material was presented at the North
American Skull Base Society Annual
Meeting, February 12, 2016, Scottsdale,
Arizona, podium presentation.
Correspondence:
Ravi N. Samy, MD,
Division of Otology/Neurotology,
Department of Otolaryngology,
University of Cincinnati College of
BACKGROUND: The middle cranial fossa (MCF) approach is a challenging surgical
technique for the resection of small and intermediate sized, primarily intracanalicular,
vestibular schwannomas (VS), with the goal of hearing preservation (HP).
OBJECTIVE: To describe a decade-long, single institutional experience with the MCF
approach for resection of VS.
METHODS: This is a retrospective cohort study of 63 patients who underwent the MCF
approach for resection of VS from 2006 to 2016. Audiometric data included pure-tone
average (PTA), low-tone pure-tone average (LtPTA), word recognition score, and American
Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification at
presentation and follow-up. Patients with postoperative serviceable (AAO-HNS class A-B)
and/or useful (AAO-HNS class A-C) hearing were compared to those without HP. Facial
nerve function was assessed using the House–Brackmann scale.
RESULTS: The mean age and duration of follow-up were 50 ± 13 yr and 21 ± 21 mo, respec-
tively. The mean tumor size was 10 ± 4 mm. The serviceable and usable HP rates were
54% and 50%, respectively. Some residual hearing was preserved in 71% of patients. Large
tumor size (P = .05), volume (P = .03), and extrameatal tumor extension (P = .03) were
associated with poor audiometric outcomes. The presence of a fundal fluid cap (P = .01)
was a favorable finding. At definitive testing, LtPTA was significantly better preserved than
traditional PTA (P = .01). Facial nerve outcomes, tumor control rates, and durability of audio-
metric outcomes were excellent. 47% of patients pursued aural rehabilitation.
CONCLUSION: In our series, the MCF approach for VS provided excellent rates of tumor
and facial nerve function, with durable serviceable HP.
KEY WORDS: Middle fossa, Acoustic neuroma, Vestibular schwannoma, Intracanalicular, Hearing preservation,
Aural rehabilitation, Low-tone pure-tone average
Operative Neurosurgery 16:147–158, 2019 DOI: 10.1093/ons/opy126

Medicine
and UC Gardner Neuroscience Institute,
231 Albert Sabin Way,
Cincinnati, OH 45267-0528.
E-mail: Ravi.Samy@UC.edu
Received, September 6, 2017.
Accepted, April 26, 2018.
Published Online, June 8, 2018.
Copyright 
C 2018 by the
S
mall to intermediate-sized primarily
intracanalicular vestibular schwannomas
(VS) may be managed with observation,
radiation, or microsurgery. Over the past quarter
century, numerous investigators have made
attempts at early microsurgical intervention,
sometimes before confirmation of growth,
in the hopes of preserving hearing.1-14 This
approach is based upon the concern that the
window for serviceable hearing preservation
(HP) may close unpredictably. Growth has
been reported in 30% to 45% of conserva-
tively managed VS, which increases the risk
of hearing loss.15-20 Two 10-yr longitudinal
cohort studies of patients with conserva-
tively managed VS demonstrated that up to

Congress of Neurological Surgeons

ABBREVIATIONS: AAO-HNS, American Academy of Otolaryngology-Head and Neck Surgery; ABRs, auditory
brainstem responses; CISS, constructive interference in steady-state; CNAPs, cochlear nerve action potentials;
CPA, cerebellar-pontine angle; CROS, contralateral routing of sound; CSF, cerebrospinal fluid; dBs, decibels; DVT,
deep venous thrombosis; FIESTA, fast imaging employing steady-state acquisition; FFC, fundal fluid cap; FN,
false negative; FP, false positive; HP, hearing preservation; IAC, internal auditory canal; LtPTA, low-tone pure-tone
averages; MCF, middle cranial fossa; PPV/NPV, positive and negative predictive values; PTA, pure-tone average;
RS, retrosigmoid; SD, standard deviation; TN, true negative; TP, true positive; VS, vestibular schwannomas; WRS,
word recognition scores

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OPERATIVE NEUROSURGERY VOLUME 16 | NUMBER 2 | FEBRUARY 2019 | 147

KOSTY ET AL
66% of patients may lose serviceable hearing during obser-
vation, with hearing loss occurring even in the absence of
tumor growth.21,22 These rates of hearing loss approximate those
described for both radiation and surgery.16,21-27 When presented
with all 3 options, we find that many patients choose inter-
vention, perhaps due to impaired quality of life associated with
the knowledge of harboring a VS.28
When HP microsurgery is elected, primarily intracanalicular
tumors may be removed via 2 approaches: middle cranial fossa
(MCF) or retrosigmoid (RS). Since it was first described by Dr
House in 1963,29 the MCF approach has gained popularity for its
ability to achieve excellent tumor control while preserving facial
nerve function and hearing. Utilizing this approach, serviceable
HP rates of 33% to 77% may be achieved.12,30,31 Mounting
evidence suggests that even historically nonserviceable hearing
may be useful to a patient, particularly with the use of aural
rehabilitation devices.
In this study, we review our institution’s 10-yr experience with
the MCF approach including HP, facial nerve function, tumor
control, and complications. We further describe varying degrees
of HP in patients with nonserviceable hearing and discuss the use
of devices to facilitate aural rehabilitation.
METHODS
Patient Selection
With institutional review board approval, we reviewed the records of
patients at our tertiary referral center who underwent VS resection via the
MCF approach from 2006 to 2016. Patient consent was not required for
this retrospective study. Inclusion criteria were as follows: histopathologic
diagnosis of schwannoma, no prior surgery or radiation, follow-up of
≥5 mo, and preoperative intent to pursue HP. Routine postoperative
follow-up was obtained as clinically indicated, generally within 2 wk of
discharge from the hospital, at 3 to 6 mo intervals for the following year,
and yearly thereafter.
Data Collection
Clinical variables included age, gender, tumor laterality, presenting
symptom, diabetes mellitus, tobacco use, and neurofibromatosis type II.
Pre- and postoperative facial nerve function was graded I-VI according
to the House–Brackman scale.32 Nerve of origin was documented if this
could be discerned from operative notes. Complications were reviewed.
Major complications included entities deemed to be immediately life
threatening: cerebral-vascular accident, seizure, epidural hematoma,
cardiac events, bacterial meningitis, and pulmonary embolism. All other
complications were considered minor. These included cerebrospinal fluid
(CSF) leak, deep venous thrombosis (DVT), and wound infections.
Revision procedures and/or salvage radiotherapy were documented.
Multidisciplinary hospital and clinic notes were obtained from several
providers to limit observer bias.
All patients received preoperative MRI. Using this, tumor size was
measured as the greatest measurable medial-lateral extent on gadolinium-
enhanced, axial T1 images. The presence of cerebellar-pontine angle
(CPA) extension and a fundal fluid cap (FFC) was noted. The FFC
was determined via specialized T2 imaging techniques (fast imaging
148 | VOLUME 16 | NUMBER 2 | FEBRUARY 2019
employing steady-state acquisition (FIESTA) or constructive interference
in steady-state (CISS)) using a protocol described elsewhere.6 Tumor
volume was approximated from the ellipsoid formula (V = ABC ×
0.52) where A/B/C were orthogonal tumor dimensions: A = greatest
medial–lateral dimension; B = greatest anterior–posterior intra-
canalicular dimension; and C = greatest cranial–caudal intracanalicular
dimension.11,33
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Audiometric Analyses and Aural Rehab
Standard pure-tone averages (PTAs) were calculated in decibels (dBs)
hearing level from air-conduction thresholds at 0.5k, 1k, 2k, and 3k
Hz. Additionally, low-tone pure-tone averages (LtPTA) were calculated
from averaged thresholds at 0.25k, 0.5k, and 1k Hz. Word recognition
scores (WRS) were recorded as % correct. Based on PTA and WRS,
patients were assigned pre- and postoperative American Academy of
Otolaryngology-Head and Neck Surgery (AAO-HNS) Hearing Classi-
fications (A-D) as well as WRS Classifications.9,30 The WRS Classifi-
cation is based entirely on SDS and considered by some to be a more
relevant metric of HP.9 Changes in LtPTA, PTA, WRS and AAO-HNS
Class were documented over time. Audiometric outcomes were defined
as serviceable (class A and B), nonserviceable (class C and D), useful
(class A-C) and residual (any class, with WRS >0% and PTA <110 dB).
Aural rehabilitation was tracked by use of hearing rehabilitation devices
including hearing aids, contralateral routing of signal devices (CROS,
BiCROS), and osseo-integrated implants.
Intraoperative neurophysiologic data were tabulated. This included
auditory brainstem responses (ABRs), and, after 2012, cochlear nerve
action potentials (CNAPs). ABRs were measured using the standard
techniques. For CNAPs, a 2-mm platinum electrode was placed intra-
operatively adjacent to the cochlear nerve. Baseline thresholds were
measured at induction of anesthesia and before resection.
Surgical Protocol
All MCF procedures included use of continuous facial nerve
electromyographic monitoring, ABRs, and CNAPs. Prophylactic antibi-
otics, dexamethasone, and levetiracetam were administered preopera-
tively. A lumbar drain was utilized in all patients to achieve decom-
pression of CSF spaces.
Details of the MCF procedure have been described elsewhere.3 Briefly,
a 4 × 4 cm temporal craniotomy was performed. The dura was bluntly
dissected from the middle fossa floor. A Fisch dural retraction system
(Bausch and Lomb, Tampa, Florida) was placed with the minimization
of temporal lobe retraction. Following blue-line identification of superior
semicircular canal, drilling exposed the internal auditory canal (IAC)
and posterior fossa dura. The labyrinthine segment of facial nerve was
decompressed and traced to its meatal segment. The CPA was entered
and the facial nerve identified there. Tumor resection then commenced.
During dissection, a loss or significant change in the ABR and/or CNAP
prompted a pause in the procedure and application of papaverine soaked
gelfoam (Pfizer Inc, West Chester, Ohio) to the IAC. Surgery recom-
menced following either normalization of the evoked responses or failure
to normalize in 10 min. Closure of the dural defect was aided by free
temporalis muscle and fascia. Bone wax was used to occlude any opened
air cells. Fibrin sealant (Tisseel, Baxter International, Deerfield, Illinois)
was placed along the tegmen to reduce risk of postoperative CSF leak.
The lumbar drain was removed immediately following surgery. Parenteral
levetiracetam was continued for 7 d.
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 HP FOLLOWING MCF FOR VS

Predictive Value of Intraoperative Monitoring

Data from intraoperative ABR/CNAP were utilized to calculate TABLE 1. Preoperative Patient Characteristics
positive and negative predictive values (PPV/NPV). Definitions were
Patient characteristics
as follows: True Positive (TP) = ABR/CNAP declined without
recovery during the case and the patient developed class D hearing; Age in years (mean ± rSD, range) 50 ± 13, 13-72
False Positive (FP) = ABR/CNAP declined without recovery during Gender (% female/male) 48/52
the case and the patient developed class A/B/C hearing; True Negative Presenting symptom (%)
(TN) = ABR/CNAP was normal or fully recovered during the Sudden hearing loss 16 (25)

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case and the patient developed class A/B/C hearing; False Negative Asymmetric (stable) hearing loss 26 (41)
(FN) = ABR/CNAP was normal or fully recovered during the case and Vestibular complaints 24 (38)
the patient developed class D hearing. A decline in ABR/CNAP was Chronic headache 3 (5)
Facial weakness 2 (3)
defined as ≥50% drop in amplitude and/or ≥10% increase in latency.
Facial twitching 1 (2)
Facial nerve function (%)
Statistical Analyses House–Brackmann I/VI 61 (97)
Analyses were performed using GraphPad Prism 6.0 (GraphPad House–Brackmann II/VI 2 (3)
Software Inc, La Jolla, California) and MedCalc 13.3.0.0 (MedCalc Audiometry
Software bvba, Ostend, Belgium). Demographic, clinical, and some Preoperative PTA in dB HL (mean ± SD, range) 31 ± 17, 5-66
radiographic data were documented categorically and compared via Preoperative WRS % correct (mean ± SD, range) 82 ± 20, 36-100
Fisher’s exact test or the Chi square test. Continuous variables were Preoperative AAO-HNS (%)
summarized by mean ± standard deviation (SD) or median with 95% A 32 (52)
confidence intervals depending on normality of distribution as deter- B 15 (24)
mined by the Kolmogorov–Smirnov test. Comparisons of normally C 9 (14)
D 5 (9)
distributed continuous variables were performed via paired/unpaired,
Tumor characteristics
2-tailed Student’s t-tests. Comparisons of nonnormally distributed
Side (% Left/Right) 51/49
continuous variables were performed via the Mann–Whitney sum ranks
Size of tumor in mm (mean ± SD, range) 10 ± 4, 3-19
test and the Wilcoxon test. P < .05 indicated statistical significance. Patients with extrameatal tumor extension (%)
Missing data were excluded as applicable. 0 mm 25 (46)
1-5 mm 21 (42)
> 5 mm 7 (12)
RESULTS Nerve of origin (%)
Superior vestibular nerve 11 (17)
General Findings
Inferior vestibular nerve 42 (67)
Sixty-five patients underwent the MCF approach for VS; 2 Undetermined 8 (13)
were excluded due to inadequate follow-up (Table 1). The mean
SD, standard deviation; PTA, pure-tone average; dB, decibel; HL, hearing level; WRS,
postoperative follow up was 21 ± 21 mo (range 5-78). Fifty- word recognition score; AAO-HNS, American Academy of Otolaryngology Head Neck
one of 63 patients (81%) achieved an HB 1 outcome and 11/63 Surgery; mm, millimeters.
(17%) achieved HB 2 facial nerve outcome at last follow-up. The
remaining patient suffered a complete facial nerve transection
requiring a cable nerve graft (great auricular nerve), ultimately improvement in median WRS (86%-98%, P = .007). This came
achieving an HB V. despite small but significant drops in LtPTA (−7.1 ± 6.6 dB;
P = .003) and PTA (−8.9 ± 7.0 dB; P = .001). When the entire
Audiometric Analyses cohort was considered, there were small but significant declines
Hearing Class Outcomes. Fifty-three patients had adequate in mean LtPTA (18.3 ± 10.3dB-26.8 ± 10.6dB; P < .001) and
audiometric data for this analysis, detailed in Tables 2 and 3. mean PTA (25.7 ± 15.5 dB-36.5 ± 14.8 dB; P < .001). For all
The AAO-HNS serviceable HP rate was 54% (22/41). Fifty patients in our cohort, low-tone hearing was preserved to a signif-
percent (24/48) of patients ultimately maintained useful HP (class icantly greater degree than high-tone hearing (P = .01). Of the 24
A/B/C). Seventy-one percent of patients (38/53) maintained patients with class D outcomes, 16 (69%) ultimately developed
some residual hearing above anacusis. anacusic ears (Table 2, Figure 1).
Excluding the 5 patients presenting as class D, 17/48 (35%) Variables associated with outcomes. We examined variables
patients maintained their presenting AAO class. One class B associated with loss of both serviceable and useful hearing
patient improved to class A hearing at definitive follow-up. A total (Table 4). Larger tumor maximum dimension, larger volume, and
of 6 of 48 (13%; all preoperative class A) declined 1 class level. The CPA extension were associated with hearing loss. The serviceable
remaining 24/48 (50%) patients (13-A, 6-B, and 5-C) declined HP rate for tumors <10 mm was greater than that for tumors ≥10
to class D. These data are depicted in Figure 1. mm in the medial–lateral dimension, approaching significance
PTA and LtPTA. In the patients who preserved/improved (54% vs 28%, χ 2 = 3.88, P = .05). Figure 2 demonstrates these
their AAO class, 12 (67%; 6-A, 6-B) experienced a significant potentially unfavorable tumor characteristics. All 4 patients with

OPERATIVE NEUROSURGERY VOLUME 16 | NUMBER 2 | FEBRUARY 2019 | 149

 TABLE 2. Audiometric Outcomes and Aural Rehabilitation According to Preoperative AAO-HNS Class
KOSTY ET AL

Preoperative AAO class groupings Audiometric outcomes and rehabilitation

Mean Definitive Tumor size Median Median

AAO age yrs Gender postop AAO Mean (greatest tumor CPA Definitive audiometric Mean change mo to test Aural
class n = (%) (range) (M/F) class (%) age (yr) dimension) volume extension outcomes mean ± SD from preop. (range) rehab
A 27 (51%) 47 ± 14 11/16 A 45.3 ± 11.2 11.1 ± 4mm 186.8 mm3 4/8 Lt PTA 16.3 ± 9.1 dB −6.4 ± 7.8 10.5 1/8 (12.5%)
(13-68) 8/27 (30%) (18.8-593.5) PTA 20.4 ± 7.8 dB −8.4 ± 6.7 (1-78) BTE HA-1
WRS 98 ± 4.2% 0 ± 3.0
B 49.3 ± 14.6 6.7 ± 2.1mm 49.5 mm3 0/6 Lt PTA 31.4 ± 4.0 dB −16.4 ± 5.3 19 3/6 (50%)
6/27 (22%) (18.4-117.8) PTA 40.1 ± 6.8 dB −20.7 ± 3.0 (6-44) BTE HA-2

150 | VOLUME 16 | NUMBER 2 | FEBRUARY 2019

WRS 92 ± 9.1% −3.3 ± 17.4 ITC HA -1
C – – – – Lt PTA –
0/27 PTA – – – –
WRS –
Db 47.3 ± 16.6 10.9 ± 4.8mm 223.2 mm3 7/13 Lt PTAb 71.1 ± 24.3 dB −54.4 ± 22.6 8 7/13 (54%)
13/27 (48%) (37.7-381) PTAb 71.9 ± 8.9 dB −53.2 ± 5.6 (2-31) OI-1
WRSb 15 ± 25.4% −80 ± 20.8 (Bi)CROS-3
Dead Earsb −10/13 Awaiting-3
B 14 53 ± 13 9/5 A/Ba 55.6 ± 15.7 7.8 ± 3.5mm 100.5 mm3 2/8 Lt PTA 30.4 ± 7.5 dB −5.4 ± 5.6 6.5 5/8 (62%)
(26%) (29-72) 8/14 (57%) (9.4-197.8) PTA 44.2 ± 9.8 dB −7.1 ± 7.6 (2-77) BTE HA- 5
WRS 83.5 ± 10.6% +13.5 ± 18.2
C Lt PTA –
0/14 (0%) – – – – PTA – – – –
WRS –
Db 50.7 ± 10.1 12.2 ± 4.7mm 169.6 mm3 3/6 Lt PTAb 77.9 ± 21.8 dB −42.9 ± 10.0 40.5 3/6 (50%)
6/14 (43%) (117-1330) PTAb 78.1 ± 13.2 dB −41.3 ± 17.7 (1-71) OI-1
WRSb 2.5 ± 3.5% −73.5 ± 26.1 BiCROS- 1
Dead ears −4/6 Awaiting-
1
C 7 56 ± 5.4 4/3 C 58.5 ± 6.4 7.0 ± 2.8mm 134.0 mm3 0/2 Lt PTA 40.8 ± 5.8 dB −5.0 ± 9.4 6 1/2 (50%)
(14%) (48-63) 2/7 (29%) (41.8-226.1) PTA 59.2 ± 8.2 dB −4.7 ± 3.8 (3-9) BTE HA-1
WRS 82 ± 2.8% −6 ± 2.8
Db 55.0 ± 5.4 12.8 ± 4.1mm 214.6 mm3 2/5 Lt PTAb 81.7 ± 23.2 dB −25.8 ± 18.3 4 2/5 (40%)
5/7 (71%) (94.2-1319) PTAb 76.4 ± 16.3 dB −21.1 ± 15.0 (3-42) BiCROS-1
WRSb 17 ± 8.2% −53.5 ± 12.1 Awaiting-1
Dead earsb −1/5
D 5 52 ± 12 2/3 Db 52.2 ± 11.8 10.4 ± 3.3mm 130.8 mm3 4/5 Lt PTA 45.4 ± 28.6 dB −14.5 ± 42.2 8 3/5 (60%)
(9%) (37-68) 5/5 (100%) (31.4-272.1) PTA 63.9 ± 19.1 dB −38.9 ± 31.8 (5-34) OI-1
WRS 31 ± 19.2% −9 ± 21.5 BiCROS-1
Dead ears −1/5 (20%) Awaiting-1

AAO, American Academy of Otolaryngology; N, number of patients; Yrs, years; M/F, male/female; mm, millimeters; CPA, cerebellar pontine angle; mo, months; BTE, behind the ear; ITC, in the canal; HA, hearing aid; OI,
osseointegrated implant; CROS, contralateral routing of signal; Lt, low tone; PTA, pure tone average; WRS, word recognition score; dB, decibel.
a
Note: one patient with preoperative class B hearing improved to class A at definitive follow up.
b
In patients with class D hearing, dead ears for the purposes of this study were those with WRS 0% AND PTA > 100 dB. Definitive audiometric outcomes for ears not meeting these criteria are provided in the table
above.

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TABLE 3. Pre- and Postoperative Word Recognition Score Classification
Preoperative word recognition score classification I (70%-100%)
I (70%-100%) 19 (58%)
II (50%-69%) 3 (27%)
III (1%-49%) 0 0
IV (0%) 0 0
FIGURE 1. Audiometric outcomes by AAO-HNS Class. Scatterplot demon-
strating both patients’ preoperative AAO class (alphanumeric ‘dots’) and definitive
postoperative AAO-class outcome (location of the alphanumeric ‘dots’). The X-axis
depicts word recognition score (WRS, % correct). The Y-Axis depicts pure-tone
average (PTA) in dB HL. The exploded box in the bottom right corner depicts the
patients who ended with an anacusic ear (WRS 0, PTA > 110).
FIGURE 2. Preoperative MR findings associated with poor audiometric outcomes.
Axial FIESTA MR sequence depicting a vestibular schwannoma with CPA
extension (arrow) and lack of fundal fluid.
OPERATIVE NEUROSURGERY
HP FOLLOWING MCF FOR VS
Postoperative word recognition score classification
II (50%-69%) III (1%-49%) IV (0%) Total
0 3 (9%) 16 (48%) 33 (100%)
3 (27%) 3 (27%) 2 (19%) 11 (100%)
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2 (50%) 2 (50%) 4 (100%)
0 0 0
evidence of tumor extension into the vestibule developed anacusic
ears (Figure 3). The presence of an FFC (Figure 4) was signifi-
cantly associated with serviceable (P = .01) and useful (P = .02)
HP.
Intraoperative monitoring and predictive value. Forty patients
had adequate data for this analysis. The results are presented in
Table 5.
Aural Rehabilitation
A breakdown of our aural rehabilitation experience is provided
in Table 2. Ultimately, 47% (25/53) patients sought rehabili-
tation. A hearing aid was the preferred device in all class A/B,
and one class C patient. Six patients received CROS/BiCROS and
three have osseo-integrated implants. An additional 6 are awaiting
insurance approval.
Outcome Durability
Ultimately, 23 patients had sufficient data for mid-to-long
term outcomes (36.0 ± 20.4 mo, range 12-78). Definitive AAO-
HNS hearing classes were 4-A, 7-B, and 12-D. All postoperative
class outcomes remained stable from early postoperative testing
through definitive follow-up. In non-class D patients, declines in
median PTA (31.6 dB-37.8 dB, P = .01) and median LtPTA (20
dB-33.3 dB, P = .01) were detected. Changes in WRS were not
significant (96%-88%; P = .22).
Tumor Control
Gross total resection was achieved in 97% of patients. In 2
patients, a capsular rind was left on the facial nerve. Tumor
recurred in 1 of these patients. Three additional patients had
recurrent tumor (6.3% recurrence rate). Of the 4 recurrences, 3
are being observed with serial imaging. One patient underwent
hypofractionated radiation and achieved tumor quiescence. The
tumor control rate was 98.5%.
Complications
The major complication rate was 3.1% (2/63). One patient
suffered an ischemic stroke and made a full recovery. A second
patient developed an epidural hematoma requiring operative take-
back but suffered no neurological deficit. The minor compli-
cation rate was 13% (8/63) including 2 wound infections, 3
DVTs, and 3 CSF leaks (all resolving following lumbar drain
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KOSTY ET AL

TABLE 4. Variables Associated With Hearing-Preservation Outcomes

Serviceable hearing (AAO class A and B) Useful hearing (AAO class A-B-C)

Not Not
Preserved preserved Significance Preserved preserved Significance

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Demographic and clinical data
Patients (n=) 22a 19a – 24b 24b –
Median F/U months 9 13.5 P = .62 9.5 12.5 P = .92
(95%CI) (10-29) (11-34) (6-25) (6-31)
Gender P = 1.0 P = .77
male 10 9 11 13
Female 12 9 13 11
Mean age yr ± SD 50 ± 14 48 ± 15 P = .61 51 ± 14 50 ± 13 P = .78
(range) (28-72) (13-67) (28-72) (13-68)
Chief complaint P = .38 P = .63
SSNHL 4 8 5 10
ASNHL 9 6 10 10
Vestibular Sx 12 7 12 10
Headache 1 1 1 2
Active smokers 6 6 P = 1.0 7 7 P = 1.0
Diabetes mellitus 3 0 P = .23 3 1 P = .65
Laterality P = 1.0 P = .77
right 11 9 13 11
Left 11 9 11 13
Radiographic data
Mean maximum size mm (±SD) 8.9 ± 3.5 10.5 ± 4.3 P = .19 8.6 ± 3.7mm 11.6 ± 4.5mm P = .05
Median volume mm3 (±SD) 128 ± 124 310 ± 413 P = .10 138 ± 493 406 ± 133 P = .03
Tumors with CPA extension 2 9 P = .03 6 12 P = .06
Fundal fluid cap 13 4 P = .02 14 5 P = .01
Tumors in vestibule 0 3 P = .08 0 4 P = .11
Nerve of origin
Superior vestibular 5 4 P = .90 5 5 P = 1.0
Inferior vestibular 13 13 15 16
Unidentified 4 2 4 3
Preoperative audiometric presentation
Mean LtPA dB HL (±SD) 17 ± 8.5 18 ± 9.6 P = .46 18.3 ± 10.3 25.6 ± 15.5 P = .06
Mean PTA dB HL (±SD) 23 ± 13 23 ± 13 P = .8 25.8 ± 15.5 31.8 ± 18.3 P = .22
AAO classification 11 P = 1.0 14 13 P = .41
A 14 5 8 6
B 8 – 2 5
C –
Mean WRS % (±SD) 87 ± 17 90 ± 12 P = .5 87.2 ± 16.4 84.8 ± 14.9 P = .59
Time to definitive audiogram
Median months 19 11 P = .28 10.5 8.0 P = .68
(range) (1-77) (1-71) (1-77) (1-71)

AAO; American Academy of Otolaryngology; CI; confidence interval; SSNHL; sudden sensorineural hearing loss; ASNHL; asymmetric sensorineural hearing loss; SD; standard
deviation; mm; millimeter; CPA; cerebellar pontine angle; LtPTA; low-tone pure-tone average; PTA; pure-tone average; dB; decibel; HL; hearing level; WRS; word recognition score.
a
12 patients were excluded from the sub-analysis on serviceable hearing preservation as they presented with nonserviceable hearing (AAO class C or D) preoperatively.
b
5 patients were excluded from the subanalysis on useful hearing (AAO class A, B, and C) preservation as they presented with class D hearing preoperatively.

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 HP FOLLOWING MCF FOR VS

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FIGURE 4. Preoperative MR findings associated with hearing preservation. Axial
FIGURE 3. Tumor with extension into the basal turn of the FIESTA MR sequence depicting a small intracanalicular tumor with a fundal
cochlea. Axial T1, Gadolinium enhanced MR image depicting fluid cap (Arrowhead).
tumor extension in the basal turn of the cochlea (Arrow).

placement). No postoperative seizures or temporal lobe contu-
sions were noted.
DISCUSSION
In our retrospective review of patients undergoing MCF
approach for small-intermediate primarily intracanalicular VS,
we observed a serviceable HP rate of 54% and a facial nerve
preservation rate of 98%. These data are consistent with prior
reporting (Table 6), as is the durability of results.1,7,34 We report,
for the first time, improved low tone versus standard range HP,
which may contribute to underappreciated functional hearing
even in patients with nonserviceable outcomes.
Variables Associated With Outcomes
In our patients, larger tumor maximum dimension, volume,
and cerebellopontine angle extension were associated with poor
audiometric outcomes. Conversely, the presence of an FFC was
a predictor of better outcomes. The association between tumor
size and HP has been previously described,3,35-39 though others
find no relationship.2,10-12,40-42 In the present study, signif-
icant associations were detected between tumor size/volume and
either serviceable or usable HP, but not both. This discrepancy
highlights the underpowered nature of the present review, and as
such, the results should be cautiously interpreted.
Low-Tone HP
Upon closer inspection of our audiometric subanalyses,
one notable finding was the improved preservation of LtPTA
compared to PTA. It has long been known that basal-turn struc-
tures within the cochlea (high-tone hearing) are more prone to
vascular insult than apical ones (low-tone hearing).43 We suspect
that the preferential preservation of LtPTA noted in our cohort
was due to this phenomenon. The importance of this preservation
pattern is illustrated by recent studies in the audiologic literature
that place considerable value on low-tone hearing during complex
listening tasks. In cochlear implant recipients, advantages of Lt-
HP have included better speech recognition in noise, improved

TABLE 5. Positive and Negative Predictive Value of Irreversible Decline in Intraoperative Audiometric Monitoring for Class D Hearing Outcome

Positive Negative
True True False False predictive predictive
positive negative positive negative value value
(TP) (TN) (FP) (FN) [TP/(TP + FP)] [TN/(TN + FN)]
Auditory brainstem reflex 13 19 3 5 81% 79%
Cochlear nerve action potential 9 13 1 3 90% 81%

True positive: monitoring modality declined without recovery during the case and patient had class D hearing at definitive follow-up; True negative: monitoring modality did not
change or changes were recovered by the end of the case and patient had class A/B/C hearing at definitive follow-up; False positive: monitoring modality declined without recovery
during case and patient had class A/B/C hearing at definitive follow-up; False negative: monitoring modality did not change or changes were recovered by the end of the case and
patient had class D hearing at definitive follow-up.

OPERATIVE NEUROSURGERY VOLUME 16 | NUMBER 2 | FEBRUARY 2019 | 153

 KOSTY ET AL

TABLE 6. Review of the Literature on Middle Fossa Cranial Approach for Resection of Vestibular Schwannomas.

Preoperative Postoperative Facial nerve

AAO-HNS AAO-HNS function
Preoperative classification classification at last follow-up Complications
serviceable Serviceable

154 | VOLUME 16 | NUMBER 2 | FEBRUARY 2019

Follow- hearing hearing CSF
Ref. N up (mo.) rate A B preserv. ratea A B HB 1 HB 2 Leak Infx. Other

Current 63 21 76% 32 15 54% 9 13 51 11 3 2 1 (1.5%) Stroke

study (52%) (24%) (22%) (32%) (81%) (17%) (5%) (3%) 1 (1.5%) Epidural hematoma
3 (5%) DVTs
Arts (2012) 73 – 85% 34 28 73% 21 24 61 8 – 1% 4 (5%) Aseptic meningitis
(47%) (38%) (28%) (33%) (85%) (11%) 1 (1%) transient expressive
aphasia
Brackman 333 0.5 90% 199 101 59% 109 87 – – – – –
(2000)2 (60%) (30%) (33%) (26%)
Colletti 35 – 100% 16 19 52% 4 14 22 5 0% – 5 (14%) Cerebellar edema
(2005) (46%) (54%) (12%) (40%) (63%) (14%) 1 (3%) headache
1 (3%) epidural hematoma
DeMonte 30 – 91% 21 5 73% 15 7 100% – 1 1 1 (3%) Epidural hematoma
(2012)61 (70%) (21%) (50%) (23%) (3%) (3%)
Gantz 43 – 64% – – 33% – – 24 12 4 1 1 (2%) Death
(1986)12 (56%) (28%) (9%) (2%) 1 (2%) pulmonary embolism
Ginzkey 89 – 81% 47 18 58% 25 25 82 3 – – –
(2013)11 (59%) (23%) (32%) (32%) (89%) (3%)
Gjuric 735 – 78% 256 133 38% (52% in 114 74 72% 20% (9% 16 9 3 (0.4%) Death
(2001)3 (51%) (27%) patients with IC (23%) (15%) (90% for for IC (2.2%) (1.2%) 2 (0.3%) CPA hematoma
only) IC tumors) 2 (0.3%) temporal lobe
tumors) contusion
1 (0.1%) seizures
45 (5.7%) transient
neurological deficits
Goddard 101 2.5 90% 65 27 27 27 29 – – – – –
(2010)6 (64%) (27%) (44%) (26%) (29%)

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 TABLE 6. continued

OPERATIVE NEUROSURGERY
Preoperative Postoperative Facial nerve
AAO-HNS AAO-HNS function
Preoperative classification classification at last follow-up Complications
serviceable Serviceable
Follow- hearing hearing CSF
Ref. N up (mo.) rate A B preserv. ratea A B HB 1 HB 2 Leak Infx. Other

Hilton 78 48 100% 64 14 65% 22 29 – – – – –

(2011)7 (82%) (18%) (28%) (37%)
Irving 48 10 98% 24 23 52% 10 16 29 11 – – –
(1998)13 (50%) (48%) (21%) (33%) (74%) (26%)
Kanzaki 127 – 100% 71 56 37% 26 22 – – – – –
(2001)8 (56%) (44%) (20%) (17%)
Kutz 46 20 91% 24 14 55% 15 9 32 6 6 – –
(2012)36 (57%) (33%) (34%) (21%) (76%) (13%) (13%)
Meyer 162 – 77% 98 26 60% 46 29% 140 17 9 – 2 (1.2%) Aseptic meningitis
(2006)9 (60%) (16%) (28%) (18%) (86.4%) (10.5%) (5.6%) 2 (1.2%) aphasia
2 (1.2%)
Quist 57 – 86% – – 55% – – 28 1
(2015)62 (90%) (3%)
Raheja 60 15 82% 36 13 78% 14 24 90% 0 3 No seizures
(2016)40 (60%) (22%) (23%) (40%) (3.8%)
Vincent 77 102 95% 52 21 60% 25 21 96% HB – – – –
(2012)63 (68%) (27%) (32%) (27%) 1-2
Weber 49 – 69% 22 12 60% 7 11 93.8% 3 – – –
(1996)10 (45%) (24%) (14%) (22%) HB 1-2 (6.2%)
Ref, reference; DVT, deep venous thrombosis; Infx, infection rate; IC, intracanalicular.
Percentage of patients with postoperative AAO-HNS class A and B divided by preoperative AAO-HNS class A and B.

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KOSTY ET AL
sound localization, and music/melody appreciation.44-46 Similar
findings have also been described in the VS literature.47,48 In the
present cohort, we theorize Lt-HP was at least partially respon-
sible for the stability in WRS observed in our patients, potentially
due to the capacity for cortical reorganization to overrepresent
low-frequency sounds following high-frequency hearing loss.49
Residual Hearing and Aural Rehabilitation
Another notable aspect of this study is the description of
hearing rehabilitation utilized by patients following postop-
erative hearing loss. When set forth in 1995, the AAO-HNS
Classification system provided a simple dichotomization of
hearing outcomes: serviceable versus nonserviceable. Recent
studies have shown that patients with nonserviceable outcomes
(PTA ≥50 dB and ≤50% WRS) can still retain improved sound
localization and speech discrimination compared to patients
with a completely deaf ear.3,9 Overall, 45% of our patients with
nonserviceable outcomes retained some residual sound/speech
detection (Table 2).
For patients with nonserviceable hearing, there are multiple
options for hearing rehabilitation. Historically, the only option
for patients with profound single-sided hearing loss was a
device that transmits auditory signals from the impaired ear
to the good ear, known as the contralateral routing of sound
(CROS) device. A BiCROS device additionally incorporates a
hearing aid. Although CROS/BiCROS devices may be poorly
tolerated due to the perception of excessive noise,50 6 of our
patients currently use one of these systems. Osseo-integrated
implants improve upon the CROS model by percutaneously
stimulating the bone adjacent to the deaf ear, resulting in stimu-
lation of the contralateral cochlea. In nonserviceable patients
with some residual hearing, mounting evidence has suggested
osseo-integrated implants provide greater hearing benefit than
CROS/BiCROS systems.50-54 This is thought to be due to
retained capacity in the impaired ear for vibromechanical stimu-
lation, which provides the patient with a range of listening
benefits approximating those described for Lt-HP.51,52 The time
delay in acoustic signals reaching the nonoperative ear—via
ipsilateral air conduction and contralateral bone conduction—
also creates a pseudobinaural sensation that may help with local-
ization.50 Cochlear implants may also be useful in patients
with anacusis. Cochlear implants have been shown to signifi-
cantly improve both sound localization and word-discrimination
following VS resection.9,55-60 To date, however, the post-VS CI
use has largely been limited to patients with bilateral hearing
loss, or those who have undergone translabyrinthine approaches.
Investigations of CI following MCF are needed.
Strengths and Limitations
Our study is among the larger studies published to date on HP
outcomes following MCF for VS resection. The characteristics of
our cohort are similar those in other studies of the MCF approach,
supporting the generalizability of our results. To our knowledge,
156 | VOLUME 16 | NUMBER 2 | FEBRUARY 2019
it is also the only study to date that investigates more complex
audiometric parameters such as Lt-HP and provides data on aural
rehabilitation following postoperative hearing loss. The study is
limited by its small size, retrospective design, and relatively short
follow-up period. No formal audiometric data were obtained
from patients using their hearing rehabilitation devices; therefore,
the analysis of the efficacy of our hearing rehabilitation strategies
is limited only to whether patients reported using their devices.
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Finally, the formula used for assessing tumor volume in this study
is an imperfect measure for the irregular shapes of some VSs.
However, the authors felt this formula best approximated the
intracanalicular volume, which in turn likely carries the greatest
clinical/practical significance. Finally, observer bias may have
tended to underestimate HB scores, but was unlikely to influence
audiometric data.
CONCLUSION
In our experience, the MCF approach for microsurgical
resection of small-intermediate intracanalicular VS provided
durable tumor control, facial nerve outcomes, and HP results.
Morbidity and disease recurrence with the procedure were low.
In younger, relatively healthy patients with usable hearing and
smaller tumors, we believe the MCF represents an excellent
treatment option. Even patients lacking serviceable hearing at
presentation or postoperatively may still derive aural benefits due
to preservation of low-tone hearing.
Disclosures
Dr Samy has research funding from Cochlear Corporation and Otonomy Inc,
LLC, which does not pertain to this study. The authors have no personal, financial,
or institutional interest in any of the drugs, materials, or devices described in this
article.
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“Houston, we’ve had a problem here.” When the oxygen tank on the
Apollo 13 Command Module, Odyssey, exploded 200 000 miles
from Earth, the crew were forced into the Lunar Module, named
Aquarius, to survive their harrowing adventure. Aquarius was built
for 2 men to survive for 2 days, but it needed to keep 3 men alive for
4 hours to get the astronauts home. There was enough oxygen in
Aquarius for the abrupt return trip, but the power was cut to
one-fifth normal operating levels in order to keep life support
systems functioning, dropping the temperature in Aquarius to 38
degrees for those 4 days. This was but one of many challenges that
threatened the survival of the crew. In the final moments before
re-entering the Earth’s atmosphere on April 17, 1970, they returned
to the Odyssey and jettisoned their lifeboat, the Aquarius. From
https://www.nasa.gov/mission_pages/apollo/missions/apollo13.
html. Image from https://images.nasa.gov/details-S69-60662.
Credit: NASA. US Gov’t, public domain.

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